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        <p>第四部分：诊断和治疗部分<br>第一章：NCCL的形态特点<br>第一节： NCCL的形态特点<br>1.形态分类的意义：确定致病机制（病因）<br>2.形态分类的依据：临床和组织学角度<br>3.形态可分为宏观形态和微观形态<br>第二节：宏观形态<br>1.根据缺损的形态、几何结构分类<br>a.NCCL每个洞壁的命名<br>冠方边缘，龈方边缘，冠方壁，龈方壁，髓壁<br>b.髓壁角度的不同分类<br>髓壁分为大于90度的和小于90度的。<br>c.窝洞形态学分类及意义<br>楔形、圆凹形、混合形、不规则形<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/013/01.png"><br>2.根据牙龈的位置分类<br>龈上、平龈、龈下<br>3.根据深度分类——直接法<br>a.测量方式：冠方边缘到龈边缘做平行于牙齿长轴的连线测量该线到病损中心的垂直向距离<br>b.测量指数：建议使用Smith和Knigh指数<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/013/02.png"></p>
<p>4.根据深度分类——间接法<br>使用浮石粉和水以及橡皮杯清洁NCCL区域<br>前庭沟出棉卷隔湿，压入排龈线隔离病损<br>调拌硅橡胶印模材料基质和催化剂<br>注入硅橡胶印模材料充满缺损部分去除多余材料<br>取下印模前确保印模材料硬固<br>使用数字化测微计测量病损深度<br>测量完成后，应评分以供后续分类。<br>第三节：微观形态<br>1.组成<br>a.釉质在应力、生物腐蚀、摩擦的作用下产生裂纹<br>因此冠方边缘需要制备。<br>b.牙本质小管变窄堵塞，牙本质硬化、矿化程度。<br>变形能力弱，弹性若。不需要制备。<br>2.质地<br>磨损的特征：<br>a.界面光滑<br>b.有牙膏牙刷摩擦的划痕<br>c.有进展线代表应力因素活跃<br>生物腐蚀的特征：<br>a.光滑釉质有蜂窝状<br>b.本质呈波浪状或涟漪状<br>c.洞型边缘线不明显<br>第四节：致病因素与洞形态的相关性<br>楔形、圆凹形、混合形、不规则形。<br>形态分类总结（病历书写依据）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/013/03.png"></p>
<p>第二章 CDH和NCCL的临床分析和诊断<br>第一节 患者病史收集和主诉<br>1.主诉（持续时间、严重性、特点）<br>2.辨别主诉中NCCL的美学及CDH疼痛<br>3.初诊交流了解全身系统性病史及饮食生活习惯。<br>4.牙科治疗病史（关节疾病、牙体、修复治疗等）<br>5.全口根尖片对诊断很有意义。<br>第二节 临床检查和诊断<br>1.临床检查<br>a.口外检查<br>口外咀嚼肌触诊<br>工作过度或乳酸堆积<br>判断磨牙症<br>判断副功能<br>b.口内检查<br>c.牙周检查<br>去除菌斑和牙石<br>了解Miller分类<br>仔细检查退缩位点(NCCL和CDH的初始阶段)<br>判断退缩的原因（咬合干扰、化学腐蚀、不良修复体）<br>d.咬合检查<br>在CO位上颌架评估磨耗小面<br>在CR(RP)位上检查正中、前伸、侧方的干扰点<br>检查MIP位是否与CO位一致（不一致-不平衡）<br>磨耗小面（牙本质岛）代表应力负荷严重<br>2.辅助检查<br>全景、CBCT、全口根尖片<br>3.病损分析<br>楔形NCCL：牙尖斜面上的侧向力<br>圆凹开口形NCCL：咬合面平坦时所受的轴向力和剪切力<br>混合形NCCL：两者兼有<br>第三节 CDH的诊断流程<br>CDH特点：暴露的牙本质小管对外界刺激尤其是热刺激产生的尖锐疼痛，不能被其它牙体疾病解释。<br>1.空气指数法<br>第一步：气流朝向无CDH症状唇颊面获得患者无痛的基准<br>第二步：棉卷隔离怀疑有CDH的牙面距离10mm处吹气刺激约2s。<br>第三步：通过疼痛视觉模拟评分VAS定量化评分<br>第四步：0=无痛，1-3=轻微疼痛，4-6-中度疼痛，7-10=严重疼痛。<br>2.T-Scan咬合分析软件<br>第一步：测量咬合接触时间（最佳0.2s第一点到静态牙尖咬合）<br>第二步：测量咬合分离时间（最佳&lt;0.5s非正中运动时后牙分离时间）<br>第三步：超出建议值为肌肉负担过重。<br>第三章 非修复治疗方案<br>第一节：概述<br>1.寻找病因对症治疗<br>2.预防性检查<br>3.预防性的治疗策略<br>控制副功能习惯，如夜磨牙或紧咬牙<br>评估咬合早接触点，可能与CDH的发生有关<br>专业检查前不应使用脱敏剂，避免掩盖症状，影响病因的确定<br>治疗相关的牙周疾病<br>减少酸性饮食摄入，确诊胃食管返流性疾病<br>相应的控制内源性和外源性酸性物质作用。<br>避免硬毛牙刷和高摩擦性牙膏的使用，减轻刷牙力量<br>第二节：咬合治疗<br>1.概述<br>a.咬合负担致应力集中<br>b.应力集中颈部破坏釉柱<br>c.配合生物腐蚀牙齿降解<br>d.釉质破坏加速NCCL和CDH<br>2.咬合不平衡<br>a.对颌牙过萌<br>b.牙齿移位<br>3.肌肉适应<br>早接触牙齿，肌肉收缩异常。引起磨耗。<br>4.咬合治疗的适应症<br>5.咬合治疗的记录介质和记录技术<br>6.咬合治疗的选择<br>7.选择性调颌<br>第三节：化学治疗（CDH的三种脱敏方式）<br>第四节：激光治疗<br>第五节：联合治疗方案<br>第六节：牙齿美白的考量</p>
<p><strong>个人总结：主要是讲形态和诊断。形态是根据临床、组织病理来分类，分为宏观形态和微观形态，根据窝洞形态，位置，深度等来分类。洞壁各个组成部分的命名。修复时需要预备冠方壁的釉质，而不用预备髓壁牙本质的原因。诊断主要根据口外检查、口内检查、牙周检查，咬合检查等，另外还要进行辅助检查，结合缺损形态来确定病因。</strong></p>
<p><strong>本文是春节前的最后一篇推送了，我初四开始值班。提前预祝本公众号网友们春节快乐，阖家幸福，鼠年吉祥！我们年后见！</strong></p>
<p>我发文章的四个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的博客园博客地址： <a target="_blank" rel="noopener" href="https://www.cnblogs.com/zwdnet/">https://www.cnblogs.com/zwdnet/</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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